A new episode of A Shot In The Arm is out!
This week it is just me. I tell the story of Pangaea Global AIDS, a global non profit think tank and technical assistance agency that I had to be the privilege to lead for seven years, and which closed in 2017. Its a tough but ultimately positive story. Many listeners have urged me to reflected on the contribution of non-profit, non governmental organizations, what they do and what happens when they know they need to pack up shop.
In addition, an increasing number of listeners have asked why I havent commented yet on the US Prep4All and its campaign to unlock the patent of two HIV medicines that are used in HIV prevention, or PrEP. It is a tough one for me. And does not offer a simple solution.
So firstly, you are never going to hear me criticize other advocates. These are people who have put their lives on hold and some of them even put their lives on the line to fight one of the greatest menaces to human survival, HIV. They deserve our respect and support. Even when - no, especially when - you don’t necessarily understand some of the tactics.
I am deeply grateful to Peter Staley and colleagues, because what they have done is to put HIV prevention back at the top of the agenda. Historically, we have failed singularly in HIV prevention. I am also not going to criticize Gilead Sciences. Good, committed people work there, trying their best to develop and deliver new medicines, and negotiate the crazy storm that is healthcare in the US. So for total transparency, Yes, Hunuvat work for Gilead’s global access program, and we collaborate on reinvigorating the business response to AIDS.
I believe that the focus must be directed firmly at the US Government. We must collectively grasp this moment, take advantage of this activism, and the extraordinary donation Gilead has made, and demand that US Administration support and fund local agencies to incorporate PrEP into comprehensive HIV testing and prevention strategies. This of course, an administration that has already shown itself to be more than willing to undermine the rights of its citizens in exchange for the continued support of its base. Whether you like how we got here or not, biomedical HIV prevention is now available in an unparallelled way in the US. We must pull the administration by the scruff of its neck to do the right thing.
Each week, I try to spread light around leaders in the fight for abortion rights. The hugely important Women Deliver Conference took place in Vancouver, Canada. Women Deliver is THE global advocate for gender equallity and the health and human rights of girls and women. It is rooted in sexual and reproductive rights - including judgement free access to safe abortion. Its founder, Jill Sheffield and President & CEO Katya Iversen know that if you invest in girls and women, you get results for everyone.
So about Pangaea. It was founded in 2000 by the San Francisco AIDS Foundation’s Pat Christen, and Eric Goosby to be a vehicle to enable San Franciscans concerned about the global nature of AIDS, to contribute to something good and worthwhile. And wow - Pangaea developed workplace programs for large multinationals in HIV and TB. It led harm reduction programs in China and Tanzania and it challenged the status quo in Oakland, across the Bay from SF, which had shoddy HIV testing and linkage to care.
I came into the mix in 2010, when Eric had just moved to DC to become Obama’s Global AIDS Ambassador. Most of the staff went with him. I was left with a desk and a tart instruction from the then Board of the San Francisco AID Foundation that we had to move from our SF office space and find somewhere of our own.
The smartest thing I did was to hire Megan Dunbar (who I think is the world’s leading expert on Implementation Science) and we built up a team to create a compelling set of integrated, mutually reinforcing programs, including
Harm reduction in Yunnan Province in China
Improving access to HIV testing and scaling up the quality of those tests and linkage to care
Helping WHO speed through informal non-normative treatment guidelines - we called them treatment optimization
We helped the Breast Cancer awareness and treatment movement in China learn from the experiences of the HIV community
We supported the first community PrEP community advisory Board in Oakland to help MSM of color access services.
But the jewel in the crown was the collaboration with the Zimbabwe Health authorities to provide life-skills to HIV positive teenage girls, and then extend services to enable young girls and men, negative or positive to enter in the comprehensive HIV treatment and prevention national program.
No technology was too advanced or too radical for it not to be the subject of interest of patients who would one day come to rely on it to save their lives.
I think our peak came in the summer of 2016, at the second World AIDS Conference to be held in Durban, South Africa. Pangaea - in one form or another - seemed to be present in nearly all key discussions about prevention for girls and women, treatment optimization, community mobilization and private sector engagement. From our little Air BNB down the road, by the coast, we were, you could say, The Forest Gump of the AIDS response.
But even then, there were rumblings.
I remember a skype conversation on a dank, humid even looking over the Indian Ocean, talking to the core members of our Board about the risks of us becoming increasingly reliant on one particular donor. Increasingly, we were no longer an independent agency but a vassal for its bidding.
And we asked the painful question what to do if the cost of operations exceeded the ability to fund or provide services for our partners. Didn’t we have an obligation to “go away” at that point?
During the fall, those rumblings became louder.
And it culminated on a Friday evening in mid December that year. I was sitting in a laundromat off 19th avenue in San Francisco, I had flooded one of the washers by stuffing a large duvet into it, which had been, as we tended to call it “pug poo apocalypsed” by our pug, Eddie. I was waiting for the owner to ring and tell me how stupid I had been.
But the call came from the funder. They had decided not only not to proceed with one new grant proposal, but to re-allocate another major program we had spent months developing, (as usual at no cost) to another organization which in their mind could do the job better than we could.
If this sounds brutal and desperately unfair, I have to say that is how I felt. But I also knew there was no space for such feelings: immediately that the plan that the small group of Pangaea Board members and I had toyed with over the summer needed to be kicked into action.
Over Christmas, and what a joyful time that was, the Executive Committee of the Board and I spoke almost everyday, in complete confidence exploring whatever and whichever way we might save Pangaea. It was clear that if we wanted to retain some modicum of ownership of the process, we needed to act now. It could not be put off any longer.
As soon as New Year’s was out of the way, I met with our staff, and somewhat overly cool and distant from myself, I explained the news, that we were closing, that we would wind down over the coming three months, and that we would do whatever we could to help colleagues find alternative employment.
I came home that note ashen. My partner Erik consoled me with a glass of neat whisky, and I realized that I too had lost my job.
The process then took over, and I was its mouthpiece. It was a frustrating and tedious review, analysis and wrap-up of of all income, all expenditure, all liabilities. No detail was too small. I learned to pore over Excel spread sheets in ways I had not thought possible. You entered into a realm of drudgery of bureaucracy that was at the same time methodical and mystifying. As we negotiated with funders on the close down of programs, some understandably demanded the balance of funding back, some offered to allow us to keep a percentage to enable us to close down gracefully. I will always be extremely grateful to those people.
Perhaps the most difficult part of the experience was while trying to support colleagues find alternative employment - particularly those with young families - one had to assume the mantle of their rage and despair. There was no escaping the overwhelming feeling that I had failed them.
However, in turn, I was supported by a phenomenal Board, in particular, Chair Eric Roberts, a former forensic accountant, Kathleen Burke a former HR President and former CEO of her own organization, and Kathy Fisher, a tenacious lawyer. They provided the legal and financial framework for me to conduct the matters that needed conducting, but more than that, they provided a place for me to vent, and to grieve.
Whatever people tell you, being an ED of a non profit agency - whether it is a technical support or network of key populations - is one of the toughest jobs there is.
You are directly responsible for delivering a life or death mission, while at the same time, making sure you are in compliance with the most bizarre and byzantine and often contradictory Federal and State laws.
You are directly responsible for the wellbeing of you staff and your consultants.
You are always hustling for money, which is frustrating because the expertise that landed you the ED job in the first place was rooted in challenging the status quo.
For executive directors in HIV, SHRH, Hepatitis, Breast Cancer and other diseases, it is an exceptionally difficult job - and the people who do it are phenomenal. You have to be the glue that holds the organization together, and adapt to, anticipate the changing moods of donors, most of whom have little understanding of the damage that instability causes.
Someone gave me a “How To” book which recommended lessons from the management of military disasters (most notably in Vietnam). For me, of course, being British-born, the temptation was to look at Dunkirk, (which the British have to come to view as an amazing victory, but was in fact a crushing military defeat, possibly the largest by one European power over another). Needless to say, the book was not useful.
Although, actually - through news reports and articles, I did learn lessons from the US military on how to handle the winding down of Pangaea. One story that sticks in my mind (and this may be aprocryphal) is the decision made by Generals at the start of the second Iraq War not to allow any further use of Power Point presentations. The format does not encourage preparatory thinking, and can be as useless as an endless shopping list. I have never liked Powerpoint, and it was indeed very painful in early 2017 to see seven years’ work reduced to a list of bullet points.
The effort needed to be spent on developing a plan - or rather create a the mindset of planning - with the willingness to extemporize when needed. Being singularly bloody-minded also helped. The funniest thing, I still get calls from head hunters inviting me to be short term CEOs of organizations that have decided to close. What am I, a new Prince of Darkness?
No, I never want to do this again. And when experts from funders and think tanks recommend sweeping changes that will bring an end to organizations, we need to be exceptionally wary of them. How many organizations have they actually closed themselves? None? Well, shut up then.
At the end of December 2018, I received a letter from the Attorney General of the State of California informing me that Pangaea, which had closed its doors in March 2017, had now been formally closed and its 501c3 status withdrawn. For just a moment, I panicked. Where on earth should I should file this letter? It ended up in a box of Pangaea papers, hidden at the back of the garage.
However, what might have been a devastating piece of paper in previous times, was now barely a footnote. And I understood that narrative was not about failure. Pangaea’s board and staff explicitly moved programs to homes in the countries where they worked best - you will find that Pangaea still thrives in the Pangaea Zimbabwe AIDS Trust, where an exceptional group of women M&E and community mobilization experts engage communities, the Ministries of Health and the Global Fund. You find it in the work of AIDS Care China, which takes the lessons learned from programs in China, and applies them across the region.
The biggest lesson for me is about humility. Winding down Pangaea, while immensely painful, was absolutely the right thing to do. If you are doing no more than raising money to keep the lights on, you have no business being in business in the first place.
Many of us working in the AIDS movement knew in the middle of this decade, that a wave of closures was coming towards us. And here we are. There is not a single one of us who does not know of an organization that has closed, or which isn’t under immense pressure to stay afloat.
It is hard, grinding work, and it demands a rigor and gritted determination we have not seen since the start of the AIDS epidemic. But my responsibility was to own the process, lead it, and not be battered about by funders.
These are still very much exciting times: The community that embraces and incorporates science into practice is still young, and is entering a new, dynamic phase of the journey, anticipating and responding to new epidemics and health challenges. Being nimble and do rapidly what funders and international agencies cannot, will remain central.
This episode is dedicated to the hard working Executive Directors around the World. You know who you are. You are A Shot In the Arm.
References You May Find Useful:
If you are concerned, or want to learn more about HIV testing, prevention and treatment:
And for some groovy British Indie Pop from the 1990s that is still going strong, may I suggest Saint Etienne